2From your Upper Classmen Friends It all became worth it when…“...When I could sit and listen to an elderly man with severe dementia and depression for as long as he needed to talk“...When a chronic neuropathic pain patient was so touched by the fact that I held her hand during a procedure that she asked the nurse to tell my resident to call me after I had left the rotation just to thank me.”“...When I could help an older gentleman come up with smoking cessation strategies after he suffered a minor stroke.”
3Staying SaneDon’t let your empathy get fatigued! Taking an extra moment to listen to your patient is a good way to improve patient care, help your team, and make the experience more fulfilling for you!
4Day 1: Service Assignment First day you meet with Amy Pruitt, and she will assign you to a service by your interests“I have no idea what I want to do” = Consults“I’m thinking medicine” = Stroke or General Ward“I’m thinking Peds” = Pediatric consult service“I’m interested in primary care or outpatient medicine” = Presby rotation
5What’s the difference Personal opinion Do not say Peds unless you are 100% sure. If you are DEFINITELY going Peds, it will be helpful to do seizure consult, seizure consult… But this doesn’t generally offer the breadth of what’s on the shelfDr Khella at Presby is an amazing teacher, but this is a very fast paced ambulatory rotation where you may feel overwhelmed if it’s your first rotationGeneral neurology, consults, and stroke all offer a good variety; the ward services function much like medicine services
6What should I buy/borrow? BooksBlueprints – High yield and a good, broad overviewCase Files – In-depth cases that make you think about what’s going on (my personal favorite).The Yellow Pages – Dr. Pruitt will give them to you on the first day. Use these last as a review.USMLEWORLD!!! – do the neurology questions. SUPER high yield. Crucial, even
7What should I buy/borrow SuppliesGet tongue depressors from the supply closet on the floor or when you start consults, you can break them in half (so they’re jagged) and use them to test “pain”Alcohol swabs (also in every ward’s supply closet) test “cold”Pin lightReflex hammer (the dinky triangle ones suck and are hard to get reflexes with,… but they are the cheapest)Tuning forkHaving something Red is helpful for testing color visionAsk a resident if you can borrow their Panoptic…. Or you can use an ophthamoscope… if you figure out how to see the optic disk with this reliably, let me know, because I sure can’t (DO NOT lose the panoptic though… its $700 and your resident will be unhappy)
8Also helpfulMaxwell cards have a section on mental status (purple page) – YOU SHOULD ALWAYS TEST in Neuro patientsIn every other rotation it’s ok to say “alert and oriented” but for neuro you need to be more specificA visual acuity card. Sometimes asking the patient to count fingers in the four quadrants of their visual field (while they look at your nose) is enough… sometimes you need to be formalMicromedex or another drug app can be very helpful
12The Neuro Exam Mental status Time? (Year, season, month, day, date) Location? (State, county, town, hospital, floor)Ask the patient to repeat 3 objects and to remember them Serial 7’s or spell WORLD backwardsAsk for the 3 objects named abovePoint to 2 objects and have the patient name themRepeat “No ifs, ands, or buts”Follow command: “Take the paper in your right hand,fold it in half and put it on the floor.”Read and obey the following written words: “CLOSE YOUR EYES”Write a sentenceCopy a design
13The Neuro Exam, Con’t Cranial Nerves Motor II: Optic: Can use the eye chart in Maxwell’s; Remember to do visual fieldsIII/IV/VI: Extraocular movement; light reflexesV: Trigeminal: You can do a variety of things, (corneal reflex, jaw opening, bitestrength), but most just test facial sensationVII: Facial: eyebrow raise, eyelid close, smile, frown, pucker, tasteVIII: Vestibulocochlear: Hearing; Rinne, Weber, doll’s eye,IX,X: Glossopharyngeal, Vagus: gag reflex, swallowing, palate elevationXI: Spinal Accessory: lateral head rotation, neck flexion, shoulder shrugXII: Hypoglossal: Tongue protrusionMotor5/5: full strength4+/5: you can break them if you push really hard4/5: Offer some resistance3/5: Can hold their arms/legs up against gravity, but are easily pushed down2/5: Can move minimally but cannot hold extremities up1/5: flicker of muscle movementGive-way weakness: you get the sense that the patient probably has full strength, but isn’t trying very hard
14The Neuro Exam, Con’t Sensation Reflexes Coordination Cold: alcohol swabPin-prick: broken tongue depressorProprioception: without looking, am I moving your big toe up or down?Vibration: tuning forkLight touch: you touch their skinReflexes0 = no reflex at all1(+) = you get a small jerk2+ = normal3+ = brisk, “jumpy” (can be normal in young people, if they are SYMMETRIC, asymmetric reflexes should make you pause)4+ = non-sustained clonus (repetitive vibratory sensation you feel)5+ = sustained clonus (rarely seen)other signs of hyperreflexia include spreading of reflexes to other muscles not directly being tested and crossed adduction of the opposite leg when the medial aspect of the knee is tappedCoordinationFinger-nose-finger, rapid alternating movement, heel to shinGait (test in everyone able to walk): tandem, heel walking, toe walking
15Where to find Neuro Exam form: Click “Housestaff Portal – Pulse” on Right side of the MedView Homepage Click Neurology on the Left side of the Screen click “common forms”
16Handling a New Admission/ ED consult Go to Medview Look up ED admissionCan see the ED’s H&P (will usually not include a neuro exam) and their initial impressions / workup that’s been doneLook and see if there are any lab abnormalities… for example a K of 2.6 may explain the patients altered mental status and take some of the “neuro” off the differential.Patients with a history of thromboembolic stroke are often anticoagulated, look at their PT if on Warfarin…If they’ve had any imaging, take a look, it’s nice to look at the images themselves, but you can also definitely use the radiology readsGo see the patient vs. look on uptodate.com if you want to know the DDx for something so that you can tailor your questions appropriatelyDo a FULL Neuro Exam. If you miss something… go back… it’s worth looking awkward to the patient, you’ll get better about being more complete as the year goes on!
17Notes on ConsultsIn the ICUs: check the paper chart first, the ICUs generally generate a daily progress note that is quite comprehensive and will give you a mostly-complete picture of the patient to that point.Comatose patients: scary at first – ask your resident if you can go together for the first one.Check pupils (II), corneals (with saline drops) (V, VII), dolls eyes (VIII), Gag (IX, X)Motor: use your reflex hammer to press (hard) on their nailbeds (it seems cruel, but this really helps you understand the patients’ overall state)Localizing: patient pulls awayExtensorFlexorTest all reflexes, including babinski
18Presenting Be methodical and thorough with history & exam In order, same way every time, go back if neededAt least at the beginning, write it out (Type!)Know everything, but only say what you actually think is important.In the beginning, all parts of the Neuro Exam are important, don’t forget the mental status (attendings will call you out if you didn’t test language… it’s a neuro thing…:/)Be prepared to answer other questionsKnow the normal values for any labs you stateFollow-Up Presentations: SOAP
19SOAP NotesSubjective - Report on any overnight events and how pt is feeling (ask about f/c, n/v, SOB, CP, abd pain, constipation, and diarrhea.Objective - Report VS (Tm, Tc, HR, BP, R, SaO2, weight), NEURO EXAMAssessment - Summary statement.Plan - plan for pt, often in order of importance of problem, by problem or by organ system.
20Topic PresentationsStart with a summary source: UpToDate, Neurology (Journal),Be focused --> brevity is the soul of wit here more than everMake a handout, but say more than is on the handoutIncorporate actual evidence (use UpToDate or reviewEnd strong: Zinger, 3 take-away points
23Support Systems Suite 100: - JoMo, Barb, Helene - Tutors set up through suite 100Organized counseling:- CAPS:- Therapists in the community (Barb from Student Affairs can provide names and contact info)- Paired mentoring: SNMA, LMSA, Elizabeth Blackwell, House mentorsOther people to turn to:- Doctoring preceptors- Advisory deans- Clerkship directors (it’s really ok to talk to them!)- Mentors you have connected with in pre-clinical years (through clinics, volunteering, etc)- Friends and family outside of medicine
24Supplemental Stuff UpToDate from Home Access the hospital's Extranet at https://extranet.uphs.upenn.edu/Use your MedView username / password to log inCreate a bookmark on your home page for UpToDateClick on the "+" that's on the far right side of the "Web Bookmarks" headingName your bookmark and put this URL in the URL spot:Click on new bookmark that's now on your home pageUse UpToDate like you would from on campusHUP OR Schedule:Homepage: Left hand side, click on Departments-->Perioperative Services-->OR Schedule. The user name and password are both hupor
25Supplemental StuffBug Drug: UPHS guidelines for anti- microbial therapyPulse:Phonebooks for each hospital#s for Consult servicesLots of assorted resources, guidelines, formsPhone #s to store in your cellHospital operatorGeneral lab